FHIR Implementation Guide for ABDM
6.5.0 - active
FHIR Implementation Guide for ABDM
6.5.0 - active
This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:ClaimResponse ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "ClaimResponse-predetermination-example-01"] ; #
fhir:meta [
( fhir:profile [
fhir:v "https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse"^^xsd:anyURI ;
fhir:link <https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse ClaimResponse-predetermination-example-01</b></p><a name=\"ClaimResponse-predetermination-example-01\"> </a><a name=\"hcClaimResponse-predetermination-example-01\"> </a><a name=\"ClaimResponse-predetermination-example-01-hi-IN\"> </a><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 737481003}\">Inpatient care management (procedure)</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href=\"Patient-example-01.html\">ABC Male, DoB: 1981-01-12 ( Medical record number: 22-7225-4829-5255)</a></p><p><b>created</b>: 2023-12-12 15:32:26+0530</p><p><b>insurer</b>: <a href=\"Organization-example-02.html\">Organization XYZ Insurance Co. Ltd.</a></p><p><b>requestor</b>: <a href=\"Organization-example-03.html\">Organization XYZ Hospital Co. Ltd.</a></p><p><b>request</b>: <a href=\"Claim-Claim-predetermination-example-01.html\">Claim: identifier = 7612345; status = active; type = Inpatient care management (procedure); subType = Emergency Claim; use = predetermination; billablePeriod = 2025-03-07 11:01:00+0500 --> 2025-04-07 11:01:00+0500; created = 2025-03-07 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Processing Complete</p><p><b>preAuthRef</b>: 123456</p><p><b>payeeType</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}\">Provider</span></p><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>10000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><p><b>reason</b>: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason covered}\">Product or Service requested is covered by the policy.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>10000</td><td>Indian rupee</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 2</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>40000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><p><b>reason</b>: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason covered}\">Product or Service requested is covered by the policy.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>40000</td><td>Indian rupee</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 3</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>20000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><p><b>reason</b>: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason covered}\">Product or Service requested is covered by the policy.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>20000</td><td>Indian rupee</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>70000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>70000</td><td>Indian rupee</td></tr></table></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-example-01.html\">Coverage: identifier = https://xyzinsurance.in/policynumber/#235037120; status = active; type = PAY; subscriberId = ABC123456BI007; relationship = Self; period = (?) --> 2026-03-17</a></td></tr></table></div>"^^rdf:XMLLiteral
] ; #
fhir:status [ fhir:v "active"] ; #
fhir:type [
( fhir:coding [
a sct:737481003 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "737481003" ] ;
fhir:display [ fhir:v "Inpatient care management (procedure)" ] ] )
] ; #
fhir:use [ fhir:v "predetermination"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/example-01" ]
] ; #
fhir:created [ fhir:v "2023-12-12T15:32:26.605+05:30"^^xsd:dateTime] ; #
fhir:insurer [
fhir:reference [ fhir:v "Organization/example-02" ]
] ; #
fhir:requestor [
fhir:reference [ fhir:v "Organization/example-03" ]
] ; #
fhir:request [
fhir:reference [ fhir:v "Claim/Claim-predetermination-example-01" ]
] ; #
fhir:outcome [ fhir:v "complete"] ; #
fhir:preAuthRef [ fhir:v "123456"] ; #
fhir:payeeType [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "provider" ] ] )
] ; #
fhir:item ( [
fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
( fhir:adjudication [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ] ;
fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "10000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "INR" ] ] ] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "eligpercent" ] ;
fhir:display [ fhir:v "Eligible %" ] ] ) ] ;
fhir:reason [
( fhir:coding [
fhir:system [ fhir:v "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason"^^xsd:anyURI ] ;
fhir:code [ fhir:v "covered" ] ;
fhir:display [ fhir:v "Product or Service requested is covered by the policy." ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "10000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "INR" ] ] ] )
] [
fhir:itemSequence [ fhir:v "2"^^xsd:positiveInteger ] ;
( fhir:adjudication [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ] ;
fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "40000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "INR" ] ] ] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "eligpercent" ] ;
fhir:display [ fhir:v "Eligible %" ] ] ) ] ;
fhir:reason [
( fhir:coding [
fhir:system [ fhir:v "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason"^^xsd:anyURI ] ;
fhir:code [ fhir:v "covered" ] ;
fhir:display [ fhir:v "Product or Service requested is covered by the policy." ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "40000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "INR" ] ] ] )
] [
fhir:itemSequence [ fhir:v "3"^^xsd:positiveInteger ] ;
( fhir:adjudication [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ] ;
fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "20000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "INR" ] ] ] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "eligpercent" ] ;
fhir:display [ fhir:v "Eligible %" ] ] ) ] ;
fhir:reason [
( fhir:coding [
fhir:system [ fhir:v "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason"^^xsd:anyURI ] ;
fhir:code [ fhir:v "covered" ] ;
fhir:display [ fhir:v "Product or Service requested is covered by the policy." ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "20000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "INR" ] ] ] )
] ) ; #
fhir:total ( [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ] ;
fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "70000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "INR" ] ]
] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "eligpercent" ] ;
fhir:display [ fhir:v "Eligible %" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "70000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "INR" ] ]
] ) ; #
fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/example-01" ] ]
] ) . #
IG © 2024+ National Resource Center for EHR Standards. Package ndhm.in#6.5.0 based on FHIR 4.0.1. Generated 2025-05-08
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